Colon, rectum and anus

Dr. sigid djuniawan,spB

 Anatomy
 The Body’s Digestive System
• Esophagus, Stomach, Small Intestine &
Large Intestine
 1st 6 feet = large bowel or colon

 Last 6 inches = rectum & anal

canal
 The anal canal ends at the anus
 cancer
 Colorectal polyps
• Hyperthrophic lymph folicles, submucosal lesion
• Carcinoid tumor : at appendix (35-40%), rectum ( 15%), colon (10%)

• Neoplastic mucosal lesion : tubular adenoma (60-80%), increase with

age, tubulovilous adenoma , vilous adenoma,

ADENOCARCINOMA SEQUENCE
DISTINGUISHING FEATURES
OF COLITIS-ASSOCIATED
COLORECTAL CANCER
 MULTIPLE POLYPOSIS SYNDROME
• Familial adenomatous polyposis : chromosome 5, rare,
• Age start :25 yo, clinical : abdominal pain, diare, hematochezia,
anemia def iron
 Signs & Symptoms
 Change in bowel  General abdominal
habits discomfort
 Blood in Stool • Gas pains
• Bright red • Bloating
• Very dark red • Fullness
• Black/Tarry Stool • Cramps
 Diarrhea  Weight loss w/ no
 Constipation explained reason
 Does your bowel feel  Constant tiredness
like it emptied  Vomiting (coffee
completely? grounds)
 Tests that examine…
Rectum, Rectal Tissue, & Blood

Aids in diagnosing & preventing colon

cancer
 Physical Exam
 General Medical History
• Includes self health habits
• Past self illnesses
• Various treatments used for previous issues
• Family health history
 If patient reports problems with respect to
signs and symptoms related to common
bowel change habits…
 Are symptoms affecting your everyday
life?
 Fecal occult blood test
 Check stool for evidence of blood
 Method
• Small samples of stool are placed on
special cards and returned to the Dr. or
Lab for testing under a microscope
 Potential harms
• False-positive & false negative results
(uncommon…serious
 Digital Rectal Exam
 The doctor or nurse inserts a
lubricated, GLOVED finger into the
rectum to feel for lumps or abnormal
areas.
 Barium Enema
 Barium is a liquid, that contains a
silver-white compound, inserted into
the rectum
 The barium coats the lower GI tract
and a series of x-rays are taken of
the lower GI tract
 AKA = a lower GI series
 What does a Barium Enema do?
 Detects
• Ulcers
• Narrowed areas (strictures)
• Growth of the lining (polyps)
• Small pouches in the wall of the
intestine
 Diverticula
• Cancer
• abnormalities
How can one prepare for this test?
 Colon must be completely empty
• Prescribed laxatives or enema (pre-
exam)
 Special Diet to follow (2 days prior)
• Clear liquids
• Tea or coffee without milk or cream
• Any juice without pulp (NO OJ or
Tomato)
• Broth
• Carbonated beverages
 Types of Barium Enemas
 Single Column
• Lie on side on Xray table
• Enema tube inserted into rectum
• Barium bag is delivered into colon
• May feel urge to have a bowel
movement….DON’T
• Though, a small balloon will keep it inside you
• Take long deep breaths through mouth…helps
relax
• May be asked to turn & rotate to evenly coat all
colon
• Then the radiologist will take a number of X-ray
images from various angles
 Air Contrast (Double contrast)
 Similar to single-column
 Big difference…Air is inflated with air
in addition to the barium to expand
and improve the quality of the
images
 Polyps can be seen easier, among
other abnormalities
 Results
 Negative = no
abnormalities are
found
 Positive =
abnormalities
found, such as
polyps.
 If positive you
may be scheduled
for further
testing.
 Cons of Barium Enema
 miss small polyps or sometimes even
small cancers
 Biopsy and polyp removal cannot be
done during testing
 you may need to follow up with a
colonoscopy
 Preparing for the procedure
(emptying the colon) and the
procedure itself can be unpleasant
 Sigmoidoscopy
 Views the rectum and
sigmoid colon areas for
polyps, abnormalities, or
cancer
 A sigmoidoscope is a
thin lighted tube is
inserted into rectum &
up through the sigmoid
colon
 May remove polyps or
tissue samples for
biopsy
 Procedure Detection
 The cause of diarrhea, abdominal
pain, or constipation
 Detect early signs of cancer in
descending (sigmoid) colon and
rectum
 can see bleeding, inflammation,
abnormal growths, and ulcers
 not sufficient to detect polyps or
cancer in the ascending or transverse
colon (two-thirds of the colon).
 Preparation Complications
 Liquid diet  Though very
 Most likely given uncommon
an enema pre-  It is likely that
procedure bleeding or a
 Air is pumped into puncture of the
colon to help colon could result
expand and see during procedure
more surface area
 Duration is 10-20
minutes
Polyp………...Removal
 Colonoscopy
 Procedure to look into entire length
of large intestine (colon) to detect
abnormalities
 Preparation, procedure, & results
same as sigmoidoscopy
 New virtual colonoscopy as
alternative procedure
 Virtual or (CT) Colonography
 a series of x-rays called computed
tomography to make a series of
pictures of the colon
 Computer then puts these pictures
together to create a detailed image
that shows polyps, etc.
Prognosis (chances of recovery)
 Depends on
• Stage : in the inner lining of colon only,
whole colon? Spread to other places in
body
• Has it blocked or created a hole in the
colon?
• Blood levels of carcinoembryonic
antigen (CEA); a substance in the blood
that may be increased when cancer is
present, before treatment begins.
• Has cancer recurred?
• Patient’s general health?
 Treatment Options
 Surgery (main treatment)
 Radiation Therapy
 Chemotherapy
 Newer targeted therapies
• Monoclonal antibodies
 Depending on stage of cancer, it is
likely that 2-3 types of treatment
may be utilized at the same time or
one after the other
 Surgery
 Removal of cancer and normal area
of colon on either side, as well as
nearby lymph nodes
 Then sewn back together
 Colostomy (bag to catch the waste
kept outside the body)
 If cancer is found early, a colonscope
can be used without cutting the
abdomen
 Radiation Therapy
 high-energy rays (such as x-rays) to kill or
shrink cancer cells
 external radiation
 internal or implant radiation; placed
directly into tumor
 Radiation can also be used to ease
symptoms of advanced cancer such as
intestinal blockage, bleeding, or pain
 Main uses is for those where cancer had
attached to an internal organ or the lining
of the abdomen
 can be aimed through the anus and
reaches the rectum without passing
through the skin of the abdomen
 Chemotherapy
 use of anticancer drugs injected into a
vein or given by mouth
 treatment useful for cancers that have
spread to distant organs
 increase the survival rate for patients with
some stages of colorectal cancer (will kill
normal cells also)
 Side effects depend on amount, length, &
type of drugs given (i.e. diarrhea, nausea,
vomiting, loss of appetite & hair, mouth
sores, increased chance of infections,
bruising & bleeding after minor cuts or
injuries & overall increased fatigue
 Risk Factors
 Age 50 or older
 Obesity (fat in waist area increases)
 30%-40% of smokers diagnosed with cancer will
die
 A family history of cancer of the colon or rectum.
 A personal history of cancer of the colon, rectum,
ovary, endometrium, or breast.
 A history of polyps or ulcerative colitis (ulcers in
the lining of the large intestine) or Crohn’s
disease.
 Certain hereditary conditions, such as familial
adenomatous polyposis and hereditary
nonpolyposis colon cancer (HNPCC; Lynch
Syndrome)
 Heavy use of Alcohol has been linked to this
cancer
 Dietary Risk Factors
 eat plenty of fruits, vegetables, and whole
grain foods
 to limit high-fat foods (especially from
animal sources) and limit excessive
alcohol consumption
 studies suggest that taking a daily
multivitamin containing folic acid or folate
can lower risk
 Other studies suggest that getting more
calcium with supplements or low-fat dairy
products can help
 Getting enough exercise is important as
well 30 min of physical activity on 5+ days
 Survival Rates
 9 of 10 people whose cancer is found &
treated at early stage (before spreading)
will live at least 5 years
 Spread to nearby organs/lymph nodes=
5years – 66% survival rate
 Spread to lungs/liver= 5 year – 9%
 (5 yr is based on percentage of patients
that were alive 5 yrs after diagnosis.
Leaving out those who died of other
causes)
 Modified Dukes Staging System
for Colorectal Cancer
 Modified Dukes A The tumor penetrates into the mucosa
of the bowel wall but no further. Modified Dukes B B1:
tumor penetrates into, but not through the muscularis
propria (the muscular layer) of the bowel wall. B2: tumor
penetrates into and through the muscularis propria of the
bowel wall. Modified Dukes C C1: tumor penetrates into,
but not through the muscularis propria of the bowel wall;
there is pathologic evidence of colon cancer in the lymph
nodes. C2: tumor penetrates into and through the
muscularis propria of the bowel wall; there is pathologic
evidence of colon cancer in the lymph nodes. Modified
Dukes D The tumor, which has spread beyond the confines
of the lymph nodes (to organs such as the liver, lung or
bone).
 Colitis
 Ulcerative colitis
• Diffuse inflamatory disease of mucosa colon and rectum
• Etiology : unknown, autoimunne respon,microba (chlamydia,
cytomegalovirus, yersinia),
• Endoscopy : granulars superficial ulcers, thickened mucosa, superficial
fissures, small pseudopolyps
• Clinical : bloody diarrhea, high fever, abdominal pain
• Therapy : corticosteroids and immunosupresive agent (azathioprine,
cyclosporine, 6-mercaptopurine), sulfasalazine is profilactic effect
(prostaglandin synthesis), surgical : children, fulminating acute colitis,
obstruction, (11%), acute toxic megacolon (6-13%)  total
proctocolectomy with ileostomy
Polyps In Colitis
Chronic Ulcerative Colitis
 Volvulus
 Def : abnormal twisting or rotation about its mesentery
 Etiologi : occlusion of lumen at each end segmen  vascular
compromise
 Location : sigmoid (50%), cecal (20-40%),transverse colon ,
splenic flexure (gastrocolic, splenocolic, phrenocolic ligaments)
 Chron’s disease
 Crohn's disease, also known as
inflammatory bowel disease, regional
enteritis, and Granulomatous ileocolitis
disease is an inflammatory disease of the
intestines that may affect any part of the
gastrointestinal tract from mouth to anus,
causing a wide variety of symptoms. It
primarily causes abdominal pain, diarrhea
(which may be bloody if inflammation is at
its worst), vomiting, or weight loss,[1][2][3]
but may also cause complications outside of
the gastrointestinal tract such as skin
rashes, arthritis, inflammation of the eye,
tiredness, and lack of concentration.[1]
 Crohn's disease can lead to
several mechanical complications
within the intestines, including
obstruction, fistulae, and
abscesses
 Diverticulitis
 Definition : saclike protrusion of colonic wall
 Congenital , aquired
 Age : 60 -65 yo
 Etiolofi : low fiber diets
 Location : caecum (2%), Colon descenden (94%)
 Clinical : bleeding
 Complication : abcess, fistula, obstruction
 Indication for surgery :
• Absolute : complication of disease , persistent pain, clinical
deteoritation

• Relative : chronis stricture, young patient, corticosteroid use,

diverticulitis
Rectum
 Surgery of rectum
 Tumor at upper rectum V LAR, distal 2 cm, prox 5 cm
 7-8 cm  abdominoperineal resection
 > 12 cm  LAR

 Pathological staging (mod Astler and Collier) : TNM

 Post opertaive : monitoring CEA
 Surgery for Rectal Cancer
 Surgery is main treatment, along with a
combination of radiation therapy
 Polypectomy, local excision, and local transanal
resection) can be done with instruments placed
into the anus,
 Stage I, II, & III rectal cancers, other types of
surgery may be done
 A low anterior resection is used for cancers near
the upper part of the rectum, close to where it
connects with the colon.
 Abdominoperineal resection is done for cancers
located close near the lower rectum-anal
conjunction. After this surgery, a colostomy is
needed
 Pelvic Exenteration:
• the surgeon removes the rectum as
well as nearby organs such as the
bladder, prostate, or uterus if the cancer
has spread to these organs. A
colostomy is needed after this
operation. If the bladder is removed, a
urostomy (opening to collect urine) is
needed
 Anus

 Symptoms : bleeding, pain, discharge, change of bowel habits

 Disorders :
• incontinence disordes, prolapse of the rectum
• hemorroids, fissura in ano, abcess, fistulo in ano, chron’s disease
• neoplastic disorders : Bowen’s disease ( SCC), Paget’s disease
(intraepithelial adenocarcinoma), BCC,
 Hemorhoid

 HEMORHOID adalah pelebaran

Vena di dalam pleksus
HEMORHOIDALIS yg tidak
merupakan keadaan patologik ,
hanya apabila homorhoid ini
menyebabkan keluhan atau
penyulit diperlukan tindakan.
 HEMORHOID DIBEDAKAN :
 HEMORHOID INTERNAL
 Pelebaran pleksus vena hemorhoidalis superior di
atas garis mukokutan dan ditutupi oleh mukosa.
 Merupakan bantalan vaskuler di dalam jaringan sub
mukosa pada rektum sebelah bawah.
 HEMORHOID EKSTERNAL
 Merupakan pelebaran dan penonjolan pleksus
hemorhoidalis inferior, terdapat di sebelah distal
garis mukokutan di dalam jaringan di bawah epitel
anus.
 POSISI HEMORHOID YANG
PALING SERING :

 . Kanan Depan
 . Kanan Belakang

 . Kiri Lateral
 PATOGENESIS
 Tiga Teori :
1TEORI MEKANIKAL :
1 Dasar : Jaringan penunjang muskulo
fibroelastik hemorhoid
interna, Park’s ligamen yang
mengalami degeneratif kelemahan
abnormal dari jaringan 
pergerakan hemorhoid 
peninggian tekanan intra
rektal  peningkatan ukuran hemorhoid.
 PATOGENESIS
2 TEORI HEMODINAMIK :
Dasar : Mikrosirkuler anal kanal mengandung arterio
venus shunt yang cenderung akibat reaksi
hormonal atau rangsangan fisiologikal,
berdasarkan pemeriksaan mikroskop elektron
dan histologi.
3 SPINCTER ABNORMAL:
Dasar : Peningkatan aktivitas spincter, menyebabkan
peningkatan tekanan jaringan dalam analkanal.
Current etiologic, pathogenic, and
paathophysiological concepts of
hemorrhoidal disease
Pathophysiology of hemorrhoids:
hemorrhoids in place but mobile
Pathophysiolohy of hemorrhoids:
Prolapsed hemorrhoids
Normal arteriovenous shunt function:
Arteriovenous shunts closed,
precapillary sphincter opened
Arteriovenous shunt dysfunction:
opening of arteriovenous shunts,
contraction
of precapillary sphincter
 FAKTOR RESIKO YANG DAPAT
MENYEBABKAN HEMORHOID :
• Gangguan fungsi usus halus mis: diare, konstipasi
• Gangguan pengosongan rektum
• Kehamilan dan melahirkan
• Pemakaian obat-obat lokal mis: enema,
supositoria, penggunaan laksan yang berlebihan
• Oral kontraseptif
• Iritasi mukosa anal kanal
• Diet yang rendah serat
• Alkohol
 GAMBARAN KLINIK:

 Nyeri
 Perdarahan

 Prolap hemorhoid

 Discharge / Mucus

 Pruritus
Examination in knee-elbow position
Examination in left lateral position
 PEMERIKSAAN
1 Terdapat mucus pada
hemorhoid
yang prolap
2 Colok dubur

3 Anuskopi

4 Proktosigmoidoscopy
 DIAGNOSA BANDING:
• Karsinoma Kolorektum
• Penyakit Divertikel
• Prolap Rectum
• Kolitis Ulserativa
• Kondiloma Perianal
• Lipatan kulit Sentinel pada garis
tengah dorsal
Macam Haemorhoid
Kelainan Anorektal
 KOMPLIKASI
1 Trombosis melingkar  nyeri
hebat
 nekrose mukosa dan kulit
penutup
(jarang)
2 Emboli septik melalui sistem

portal
 abses hati
3 Anemia
Paska Haemorhoidektomi (komplikasi)
 KLASIFIKASI
Hemorhoid interna dikelompokkan dlm 4 derajat:
 DERAJAT I :
Perdarahan segar tanpa nyeri pada waktu
defekasi. Tidak ada prolap, pada
pemeriksaan anuskopi terlihat hemorhoid
yang menonjol ke dalam lumen.
 DERAJAT II :
Menonjol melalui anal kanal saat
mengedan ringan, tetapi dapat masuk
kembali secara spontan.
 KLASIFIKASI

 DERAJAT III :
Menonjol saat mengedan dan
harus
didorong kembali sesudah
defekasi.
 DERAJAT IV :
Menonjol keluar dan tidak dapat
didorong
masuk, biasanya timbul gejala
nyeri.
Staging of hemorrhoids
 PENANGGULANGAN
A. Secara umum
B. Terapi obat-obatan
C. Skeleroterapi
D. Ligasi dengan gelang karet
E . Bedah beku
F . Infrared coagulasi
G. Metode lain
H. Hemorhoidektomi
Sclerotherapy equipment
Injection sclerotherapy
Sclerotherapy technique
Rubber and ligator with its cone
engabling fitting of a rubber band
Cryode with its nitrous oxid cylindeer
and pressure adjuster
Infrared coagulation apparatus
Indikasi metode pengobatan berbagai derajat
hemorhoid
Derajat Hemorhoid Pengobatan
I - Terapi obat-obatan
- Sklerosing metode
- Foto coagulasi
- Bipolar coagulasi diatermi
II - Terapi obat-obatan
- Ligasi gelang karet
- Heater probe
- Sklerosing metode
III - Ligasi gelang karet
- Operasi
- Terapi obat-obatan
IV - Operasi
- Terapi obat-obatan
 PILIHAN TERAPI

TRADITIONAL MODERN

I0
I0 MEDICAL
MEDICAL
II0 OFFICE
PRACTICE II0
III0
SURGICAL III0
IV0 SURGICAL
IV0
 PARADIGMA BARU

1. DIAGNOSA HEMORRHOID INTERNA HARUS

DILENGKAPI PEMERIKSAAN
PROKTOSKOPI

2. TENTUKAN : LETAK, JUMLAH DAN

BESARNYA
MASING- MASING BENJOLAN
(PENTING UNTUK EVALUASI
PROKTOSKOPI)

3. DERAJAT 3 : BISA DIBAGI MENJADI 3A

DAN 3B
 PARADIGMA BARU

DERAJAT 3A : SEPERTI KRITERIA 3 TETAPI

BILA BENJOLAN  2

DERAJAT 3B : SEPERTI KRITERIA 3 BILA

BENJOLANNYA >2 ATAU
SIRKULER

DERAJAT 3B : BIASANYA AKAN TURUN KE

DERAJAT 4.
 PARADIGMA BARU :
KONSERVATIF ----> TRIO

1. PENGATURAN DIET --> BAB

LUNAK

2. OBAT-OBAT PER-ORAL

3. SUPPOSITORIA.
 PARADIGMA BARU :
PENGATURAN DIET

1. MINUM AIR PUTIH 1 - 1½

LITER/HARI

2. BUAH-BUAHAN : PEPAYA, PISANG

3. SAYURAN

4. LARANGAN MAKAN.
 LARANGAN MAKAN

1. DAGING KAMBING
2. PEDAS
3. DURIAN
4. NANAS
5. CUKAK
6. SALAK
7. NANGKA
LAMANYA SAMPAI 6 MINGGU (1 ½ BULAN)
 PARADIGMA BARU

1. PENGOBATAN KONSERVATIF SELAMA 6

MINGGU

2. GEJALA HILANG TIDAK BERARTI

SEMBUH.

3. SEMUA GEJALA RATA-RATA HILANG

DALAM SEMINGGU PERTAMA
BEROBAT.

4. EVALUASI HARUS DENGAN

PROKTOSKOPI MINIMAL 2 MINGGU
SEKALI 3 X BERTURUT-TURUT.
 HEMORHOID EKSTERNAL YANG
MENGALAMI TROMBOSIS :
1. Rendam duduk menggunakan larutan hangat,
salep yang mengandung analgetik.
2. Istirahat di tempat tidur, untuk mempercepat
berkurangnya pembengkakan.
3. Kurang dari 48 jam dapat ditolong : segera
mengeluarkan trombus atau eksisi lengkap
dengan anastesi lokal.
 KESIMPULAN
 Hemorhoid suatu keadaan normal dari anatomi
manusia, jika mengalami perubahan diperlukan
tindakan.
 Dengan bertambahnya usia terjadi perubahan
hemorhoid yang membesar dan turun dalam lumen
anal kanal.
 Vena-vena menjadi tegang dan perubahan ini
meningkat setelah dekade ke-3 dalam kehidupan.
 Dengan meningkatnya pengetahuan struktur anatomi
dan prevalensi penyakit, akan memudahkan cara
pencegahan dan pengobatan simptomatis penyakit ini.
 PERIANAL FISTULA

LAB/SMF BEDAH SEKSI BEDAH DIGESTIV

PENDAHULUAN

~ FISTULA ANI / FISTULA IN ANO

~ CHRONIS RESIDIF.
~ FISTULA : PENGHUBUNG ANORECTAL - LUAR
~ Th/ TIDAK ADEKUAT
~ PEMBEDAHAN
~ MEMAHAMI ANATOMI, KLASSIFIKASI & TEKNIK
ANATOMI ANORECTUM
PATHOGENESIS
KLASSIFIKASI :
1. MILLIGAN MORGAN (1934)
2. PARKS (1976)

TUJUAN : ARAH & LETAK FISTULA

TINDAKAN PEMBEDAHAN
 MILLIGAN-MORGAN 1934

Subcutan Anorectal

Low Anal High Inter

Muscular

High Anal
 KLASIFIKASI PARK (1976)

SIMPLE LOW HIGH BLIND - OPEN RECTUM NO PERINEAL

SUPRALEVATOR ABSCESS PELVIC EXTENSION

INTERSPHINCTERIC
 TRANSSPHINCTERIC

UNCOMPLICATED HIGH BLIND TRACK

SUPRASPHINCTERIC EXTRASPHINCTERIC
 GOODSAL’S RULE

12

ANORECTAL
LINEA DENTATA RING

ANAL ORIFICE

6
GAMBARAN KLINIS :

~ RIWAYAT PERIANAL ABSCESS

~ CHRONIS RESIDIF
~ TERASA BASAH, PUS / CAIRAN
~ PRURITUS
PEMERIKSAAN FISIK
~ INSPEKSI LUBANG LUAR
PEMERIKSAAN FISIK
~ PALPASI (PERKIRAKAN ARAH)
PEMERIKSAAN FISIK
~ RT & SONDAGE
PEMERIKSAAN FISIK
~ RECTOSCOPY

PEMERIKSAAN PENUNJANG
~ ZAT WARNA , PERHIDROL
~ FISTULOGRAFI
~ ENDORECTAL SONOGRAFI
~ CT SCAN FISTULOGRAFI
~ THORAX PA
~ BARIUM ENEMA
~ LABORATORIUM
PEMBEDAHAN
~ SATU-SATUNYA TERAPI KARENA :
~ RISIKO SEPSIS OK ANORECTAL ABSCESS
~ PERLUASAN TIDAK TERDETEKSI SECARA FISIK
~ RECURENT (CHRONIS RESIDIF)

~ PRINSIP : MEMBUANG FISTEL BESERTA

CABANGNYA TANPA MENIMBULKAN
INCONTINENSIA.

~ PREOPERATIF :
TEKNIK OPERASI
1. LAYING OPEN TECHNIQUE

~ UNTUK FISTEL LETAK RENDAH

~ BUKA SAL.FISTEL DARI LUBANG LUAR
S/D DALAM LALU FISTULOTOMY /
FISTULECTOMY / DGN SKIN GRAFT.
TEKNIK OPERASI
2. KOMBINASI LAYING OPEN + SETON
~ UNTUK FISTEL LETAK TINGGI DGN
INTERNAL OPENING
~ SETELAH FISTULOTOMY, PASANG
SETON
~ > 1 MINGGU BUKA SBG GUIDE
TEKNIK OPERASI
3. EKSISI FISTEL + MUCOSAL ADVANCEMENT FLAP
4. RE-ROUTING TECHNIQUE

POST OPERASI
~ CEGAH PENYEMBUHAN PREMATUR DARI
LUKA KULIT LUAR SEBELUM LUKA DALAM
SEMBUH (DARI DALAM KELUAR)
~ WAKTU CUKUP LAMA
KOMPLIKASI POST OPERASI
~ RETENSIO URINE, PERDARAHAN, INCONTINEN
FISTEL REKUREN, ANAL STENOSIS
~ SEPSIS

KEKAMBUHAN
~ TIDAK SELURUHNYA TERANGKAT
~ SALAH DIAGNOSIS (TBC FISTULA)
~ PERAWATAN POST OP KURANG BAIK
KESIMPULAN
1. SANGAT PENTING UNTUK MENGETAHUI TIPE
FISTEL DAN MEMAHAMI ANATOMI SEBELUM
TINDAKAN PEMBEDAHAN.
2. PRINSIP PEMBEDAHAN FISTEL.
3. CARA PEMBEDAHAN SESUAIKAN DENGAN
LETAK FISTEL (TINGGI / RENDAH).
4. PERAWATAN POST OP MEMEGANG PERANAN
SANGAT PENTING.